COLLEGE OF ALLIED MEDICAL PROFESSIONS

BACHELOR OF SCIENCE IN NURSING

NURSING CARE PLAN

Patient’s Initial: T.F.C___________________ Age: __28___________ Date of Birth: __________________ Gender: ___________________
Chief Complaint: _____________________________________ Medical Diagnosis: _______________________________________________ Room/Bed #: _______________

DATE CLIENT’S NURSING

ROUTE OF RESPONSE
ORDERED/ RESPONSIBILITIES
ADMINISTRATION MECHANISM CONTRAINDICA (THERAPEUTIC
MEDICATION GIVEN OR INDICATION (PRIOR, DURING,
/ DOSAGE/ OF ACTION TION EFFECT, SIDE
TAKEN/ EFFECT, ADVERSE
AFTER – AT LEAST 3
FREQUENCY EACH)
DISCONTINUED EFFECT)
Generic: Date Ordered: Route: Relief of Hypersensitivity to Therapeutic Effect: Prior:
Unknown. Binds moderate to nalbuphine HCl. relieve moderate to Assess the patient's
Nalbuphine amp IV with opioid severe pain. Pre- severe pain. medical history,
Brand: receptors in the operative including allergies,
CNS, altering analgesia, as a Side Effect: previous reactions to
Date Given: Dosage: perception of and supplement to  Nausea and antibiotics, and current
Nubain 10mg/mL emotional balanced vomiting medications.
20mg/mL response to pain anesthesia,  Dizziness Assess a patient’s pain
surgical  Urinary retention level, including
anesthesia, for  Sedation location, intensity, and
Classification: Frequency: obstetrical  Lightheadedness any factors that may
Opioid Date Discontinued: Qh3 or 6/ analgesia during  Dry mouth aggravate or alleviate
analgesics As needed labor and for the the pain.
 Anorexia
relief of pain Inform the patient about
 Agitation
following acute the purpose of
myocardial nalbuphine, potential
Adverse Effect:
infarction. Post- side effects.
operative somatic  Seizure
 Fatigue Obtain baseline vital
and visceral pain. signs, including

Submitted by: Grazel Antonette B. Calub_ Section/Group #: 3A-Group 4___ Submitted to: Ma’am April Bedua_ Hospital/Area: Graman Medical Hospital_ Date: November 18, 2023_
  Constipation temperature, blood
 inattentiveness pressure, pulse, and
respiratory rate.

During:
Verify the patient's
identity using two
identifiers (e.g., name
and date of birth)
before administration.
Ensure the correct
dosage is administered
based on the patient's
weight and the specific
infection.
Ensure the patient is
comfortable during
administration.

After:
Communicate any
concerns or unexpected
findings to the
healthcare team,
including the
prescribing physician.
Schedule any necessary
follow-up appointments
or laboratory tests to
assess the effectiveness
of the medication.
Observe the patient for

Submitted by: Grazel Antonette B. Calub_ Section/Group #: 3A-Group 4___ Submitted to: Ma’am April Bedua_ Hospital/Area: Graman Medical Hospital_ Date: November 18, 2023_
 any adverse effects,
including sedation,
dizziness, nausea, or
allergic reactions.

Submitted by: Grazel Antonette B. Calub_ Section/Group #: 3A-Group 4___ Submitted to: Ma’am April Bedua_ Hospital/Area: Graman Medical Hospital_ Date: November 18, 2023_